Pathology/Lab Coding Alert

Beware FNA and cytopathology pitfalls.

When your pathologist examines multiple specimens using various procedures for a single case, do you have the tools to catch the opportunities, avoid the pitfalls, and get home by 6?

Look at the following case, then study our experts’ tips to make sure you receive all the pay you deserve — and avoid over charging for services, too.

Study the Case

The pathology report includes the following specimens, services, and diagnoses:

Clinical history: RUL mass. Procedure 1-9-2013: bronchoscopy and EBUS

Specimen A: Bronchial washing - 150 cc pink mucoid fluid

Cytology cell block

Non-gyn liquid-based preparation with interpretation

GMS

Diagnosis — histocytes, squamous cells, WBCs, bronchial cells; negative for malignant cells. Cell block findings similar to cytologic preparation. Silver stain positive for fungus, negative for pneumocystis.

Specimen B: Bronchial brushing, RUL - brush tip with small amount of red material

QNS cytology cell block

Non-gyn liquid-based preparation with interpretation

GMS

Diagnosis — reactive bronchial cells, histocytes, squamous cells, WBCs; negative for malignant cells. Silver stain negative for organisms.

Specimen C: Bronchial biopsy, RUL.

Few minute fragments of gray-tan friable tissue measuring 0.2x0.3x0.2 cm in aggregate

Wholly submitted labeled "C," paraffin embedded, H&E stained

Diagnosis — bronchial tissue, no specific abnormality; negative for malignancy

Specimen D: FNA 4R lymph node - received in cytolyte solution with 4 prepared slides

FNA adequacy #1

Thin prep FNA

Diagnosis — pulmonary macrophages, few squamous cells, unsatisfactory for evaluation, nondiagnostic. Results given by Dr. X. to Dr. Y on 1-9-2013.

Look at the following tips to help you capture services, and avoid common coding traps:

Tip 1: Choose Documented Cytology

Specimens A and B are non-gyn cytology — bronchial brushing and washing. That means you’ll report the pathologist’s exam using one of the codes from the range 88104-88112 (Cytopathology …) — but which one?

Do this: Because the path report specifies "non-gyn liquid based preparation," you should report 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid based slide preparation method], except cervical or vaginal) for each specimen (88112x2)

Caution: You’ll notice that specimen D, lymph node fine needle aspiration (FNA), mentions "thin prep," which is another way to describe an 88112 service. But that doesn’t mean you should report 88112x3 for this case. Regardless of how you receive an FNA specimen or how the lab prepares the slides, you should report the service using only FNA codes (see tip 3).

"You shouldn’t additionally report other cytology preparation methods, such as 88112, with FNA," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Tip 2: Check for Surgical Specimens

Specimens A and B both mention cytology cell block — that’s a surgical pathology charge of 88305 (Level IV - Surgical pathology, gross and microscopic examination, Cell block, any source), when performed.

Watch out: QNS is a trap if you don’t know what it means — quantity not sufficient. In other words, the pathologist didn’t examine a cell block for specimen B. You’ll also notice that a cell block isn’t mentioned in the diagnosis for specimen B.

Specimen C is another surgical pathology specimen — right upper lobe (RUL) bronchial biopsy.

"You’ll find bronchial biopsy as a listed specimen under 88305 (… Bronchus, biopsy)," says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Bottom line: This case warrants billing 88305x2.

Tip 3: Gauge FNA Adequacy Check and Interpretation

Specimen D represents a lymph node FNA specimen. The pathology report notes an adequacy check and documents results given by Dr. X (your pathologist) to Dr. Y (the surgeon) on the date of the bronchoscopy. That warrants reporting 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site). You’ve already seen that you shouldn’t report 88112 for the thin prep, but what about reporting the pathologist’s FNA exam?

Check documentation: The path report only documents an adequacy check, with the result that the specimen is unsatisfactory for evaluation, which the pathologist reports to the surgeon. There’s no documentation that the pathologist evaluated an adequate specimen, so you shouldn’t bill 88173 (…interpretation and report).

Tip 4: Don’t Miss Special Stains

Specimen A and B both list GMS (Grocott Methenamine Silver) — a special stain for microorganisms. You’ll notice that the diagnosis for each specimen indicates "silver stain negative for …" or "positive for …," which provides good documentation to bill for the service.

Do this: Report the silver stains as 88312 (Special stain including interpretation and report; Group I for microorganisms [e.g., acid fast, methenamine silver]) times 2.

What about the hematoxylin and eosin (H&E) stain mentioned for the bronchial biopsy (specimen C)?

"You shouldn’t report a special stain code for H&E, because it is the commonly-applied stain for microscopic tissue examination, and is included in the surgical pathology service charge," Stainton says.

Case closed: Gather up all the codes discussed for these four specimens in this bronchial case, and here’s what you have:

88305x2 for the cell block and aggregate bronchial biopsy

88112x2 for the bronchial washing and brushing

88172 for the FNA adequacy check

88312x2 for the two GMS stains.